Making a Difference for People with Long Term Conditions NOVEMBER 2016

Frontline pharmacists: Making a difference for people with long term conditions NOVEMBER 2016

Supported by Pharmacy Voice CONTENTS

1 Introduction 2 Executive summary 3 Calculating the value of pharmacists in improving care for people with long term conditions 4 Caring for people with long term conditions 8 The patient health journey for long term conditions 9 Prevention and self-management 11 Timely detection 14 Treatment and monitoring 20 Palliative and end of life care 22 Next steps 23 References

Frontline pharmacists: Making a difference for people with long term conditions INTRODUCTION

The Royal Pharmaceutical Society (RPS) believes that pharmacists have a crucial role to play in the support of people with long term conditions.

The management of long term conditions represents a significant strain on an already overstretched primary care system and an unnecessary burden on secondary care resources through avoidable hospital admissions. The RPS believes that the expertise and clinical knowledge of pharmacists must be fully utilised to support people with long term conditions and help them to achieve the desired outcomes from their medicines, thereby making more efficient use of National Health Service (NHS) resources.

Our approach

This report takes a principle-based approach to the management of long term conditions. Taking into account the increasing prevalence of multimorbidities, it is not condition-specific but rather takes a holistic and overarching view of the potential contribution represented by the pharmacy profession to support all people with long term conditions.

This report focuses on the need to enhance the role of pharmacists as part of a multidisciplinary approach to help tackle the challenges facing the NHS in treating and supporting people living with long term conditions.

This report takes into account the main objectives of NHS England’s Five Year Forward View and proposes that optimal use of pharmacists to support people with long term conditions can:

• Improve health by maximising pharmacists’ role in health and wellbeing; • Transform care by utilising pharmacists’ skills, expertise and knowledge in medicines and their holistic approach to patient care; and • Help to control costs by reducing medicines waste and unplanned admissions to hospital by better use of medicines.

All of these are key areas outlined in the NHS Business Plan 2016/17.1

1 Frontline pharmacists: Making a difference for people with long term conditions EXECUTIVE SUMMARY 4 All pharmacists directly involved in patient care should have full read and write access to the patient The effective management of long term conditions is health record, with patient consent, in the interest widely recognised to be one of the greatest challenges of high quality, safe and effective patient care. for the NHS this century.2 More than 15 million people are currently living with at least one long term condition3 and this number is expected to continue to England specific recommendations: rise. Long term conditions place a huge burden on the NHS, particularly in primary care but also in secondary 1 Commissioners, NHS Trusts, General Practice care through avoidable outpatient appointments and (GP) surgeries and community pharmacies should visits to Accident and Emergency (A&E). develop collaborative arrangements for specific categories of patients with long term conditions to Pharmacists already play an important role in the be partly or completely managed by pharmacists. ongoing monitoring, support and treatment of 2 Commissioners should develop collaborative people living with long term conditions. arrangements to enable pharmacists with appropriate skills and knowledge to manage the The RPS believes that the expertise and clinical knowl- long term care of frail, elderly people living in care edge of pharmacists must be fully utilised to support homes and other domiciliary settings. people with long term conditions and help them to 3 Public health organisations should fund the use of achieve the desired outcomes from their medicines, community pharmacies to target specific health thereby making more efficient use of NHS resources. promotion subjects that impact on the management of long term conditions. The patient journey for people with long term 4 Steps should be taken at national and local levels conditions is represented by four stages: prevention to develop ways of working that enable healthcare and self management; timely detection; treatment and professionals to operate efficiently and effectively monitoring; and palliative and end of life care. To maximise across traditional sectors. the contribution of pharmacists to the management of 5 Pharmacists must play an important role in the long term conditions at each stage of the patient journey, safe management of people with one or more The RPS recommends the following actions: long term condition, and on several medicines (polypharmacy), by improving adherence to treatment, reducing side effects and admission to Our vision for Great Britain hospital, de-prescribing where appropriate. 6 Pharmacists will contribute, with others, to the 1 Pharmacists providing direct patient care should have prevention and screening of disease, self-care and the opportunity to train to become a prescriber, fully supporting patients diagnosed with a long term utilising those skills as part of the multidisciplinary condition from disease progression by supporting approach to managing and supporting people with their health and wellbeing. long term conditions. 7 Opportunities must be created for multidisciplinary 2 The patient journey will be made easier by enabling teams to train and develop together to encourage pharmacists to directly refer to appropriate greater collaboration and sharing of expertise. health and social care professionals, improving 8 Pharmacists must have protected time to advance patient access to care and reducing the number of their practice and to sustain their professional unnecessary appointments. development. 3 Patients will benefit from further integration of The implementation of these recommendations will pharmacists into their multidisciplinary team, ensure people with long term conditions can benefit ensuring support at every stage of their journey, from greater access to the expertise of pharmacists, from prevention through to treatment and and in the long term, create cost efficiencies across management of their long term condition(s). the healthcare system.

2 Frontline pharmacists: Making a difference for people with long term conditions CALCULATING THE VALUE OF PHARMACISTS IN IMPROVING CARE FOR PEOPLE WITH LONG TERM CONDITIONS 15M 18M More than 15 illion people in England have at least one long term condition4 By 2025, 18 illion people will have one or more long term conditions5

£15 billion was spent on Up to medicines in 8 70% is spent on caring £8,000 2015 for people with long annual term conditions6 costs for living with three or £15B Up to more long £3,000 term conditions7 ENGLAND annual £1B EALT AND costs for 70% SOCIAL CARE BUDGET living with one long Almost £1 billion was spent term on prescriptions to treat 9 condition7 and manage diabetes alone

30 50% of medicines Long term prescribed for long conditions account term conditions are 50% for 50% of all GP not taken correctly10 appointments11

54,418 registered pharmacists Up to £500 million of extra in Great Britain12 and 11,700 value could be generated if community pharmacies in medicines were used in an England13 optimal manner in just five 54,418 therapeutic areas:16 astha Adults in England visit a diaetes pharmacy on average 16 £500 m raised lood pressure 11,700 times a year14 and 1.2 illion vascular disease dail visits to pharmacies are 15 the care of people ith for health-related reasons schiophrenia ➽

3 Frontline pharmacists: Making a difference for people with long term conditions CARING FOR PEOPLE A system under pressure WITH LONG TERM The Department of Health estimates that, in England, CONDITIONS long term conditions account for around 50% of all GP appointments.26 Primary care has come under More than 15 million people in England have at increasing pressure in recent years, with higher least one long term condition17 and the effective demands on GPs and longer appointment waiting management of long term conditions is widely times. There is also growing consensus that GPs recognised to be one of the greatest challenges require longer appointments to adequately manage facing the 21st century NHS in England.18 Caring the health needs of more complex patients, such as for long term conditions currently accounts for those living with one or more long term conditions. approximately 70% of the health and social care A recent report from the Royal College of General budget in England.19 This burden is set to increase Practitioners stated that: with a projected rise in the number of people with one or more long term conditions to around 18 million by 2025.20 Only 8% of UK GPs feel that the current consultation length is long enough for patients A long term condition is often defined as a with long term conditions27 condition that cannot, at present, be cured but can be controlled by medication and other therapies. Examples of long term conditions include diabetes, Alongside this, demands on urgent and emergency heart disease, asthma and chronic obstructive care are also rising. pulmonary disease. A substantial proportion of people with long term conditions also experience co- or multimorbidity – the presence of two or Long term conditions are estimated to account more conditions simultaneously.21 for 68% of outpatient and A&E appointments and 77% of inpatient bed days.28 It has been estimated that the number of people living with multiple long term conditions is also predicted to rise to 2.9 million in 2018 (from With the average cost of a hospital stay for a 1.9 million in 2008).22 This would represent a non-elective inpatient estimated to be £1,565 significant increase in cost burden. The average per day,29 there is a clear need for more effective health and social care cost per person per year support to help manage people living with long rises exponentially with the number of long term term conditions in their communities, in order to conditions with which they are living. Costs rise improve patient outcomes and reduce hospital from just over £1,000 for someone with no long admissions. term conditions, to around £3,000 for someone with one long term condition and up to nearly £8,000 for someone living with three or more Frontline pharmacists long term conditions.23 Pharmacists already play an important role in the Department of Health data shows that long term ongoing monitoring, support and treatment of people conditions are more common in people from living with long term conditions. With more than lower socio-economic groups; those from unskilled £15 billion spent on medicines in 2015, medication is occupations (52%) suffer from long term conditions the most common intervention in the management more than groups from professional occupations of long term conditions. For example, prescriptions (33%).24 Multimorbidity is also more common to treat and manage diabetes accounted for almost among deprived populations.25 £1 billion of NHS spending in 2015.30

4 Frontline pharmacists: Making a difference for people with long term conditions As experts in medicines and their use, pharmacists “The RPS’s report is timely because the can ensure patients receive the best outcomes Independent Review of Community Pharmacy from their medicines, reduce adverse events, Clinical Services will rep ort later this year and it minimise avoidable harm and unplanned admissions will recommend how the NHS should develop and to hospital, and deliver efficient medicines use for improve clinical pharmacy services for patients.” the NHS. Adults in England visit a pharmacy on average 16 times a year.31 This frequency of access David Mowat MP, means pharmacists are ideally placed to recognise Parliamentary Under Secretary of State the early signs and symptoms of many long term for Community Health and Care conditions. Pharmacists also play an important role in preventing long term conditions by promoting health and wellbeing. “It is so important that patients have quick and As of 30 September 2016, there were 54,418 easy access to care. Being able to speak to a local registered pharmacists in Great Britain.12 pharmacist could mean that patients are able to access the right care closer to home or their The RPS believes that the expertise and clinical workplace; completely removing the challenges of knowledge of the pharmacist workforce can be booking an appointment with a GP, cutting out more fully utilised to support people with long waiting times and taking out the worry for many term conditions and help them to achieve the patients who get anxious visiting a surgery. desired outcomes from their medicines, thereby making more efficient use of NHS resources. “The Patients Association warmly welcome pharmacists becoming trained prescribers, This view has been echoed by stakeholders in many not just because it will take pressure off GP areas of the health sector. surgeries meaning a better service for patients who need to see their GP, but also because it is a better for patients who don’t need to see their GP. It is a win-win situation for patients.” “I welcome the recommendations of this report and the direction of travel which Katherine Murphy, the RPS has outlined. Chief Executive, The Patients Association “Community pharmacists are skilled, registered health professionals who are the experts in medicines use and optimisation. I want their clinical skills “National Voices congratulates the Royal to be much more available to patients Pharmaceutical Society for its consistent efforts to to help them manage not just their shape future roles for pharmacists that help create medicines but also their overall health better lives and outcomes for people with long term through the provision of healthy lifestyle conditions. In dialogue with our member charities advice. who work with hundreds of thousands of people, RPS has shown genuine commitment to mutual “This is particularly true for patients with learning and to pursuing effective person centred long term conditions who may be taking care, as reflected in this new policy position.” many medicines and where there is evidence that outcomes are not always as Don Redding, good as they could be. Director of Policy, National Voices

5 Frontline pharmacists: Making a difference for people with long term conditions “Diabetes UK fully supports the recommendations “An enhanced and more integrated role for of this report. Pharmacists are working with pharmacists in the NHS has the potential patients in their communities every day. Integrating to bring significant benefits for people with them into the multidisciplinary team could really dementia. A diagnosis of dementia is crucial support people living with diabetes and other long to get the right information, treatment and term health conditions. support, yet a third of people living with the condition still don’t have one. Pharmacists’ People with diabetes get just three hours support routine contact with patients make them ideally from traditional diabetes team members each year placed to spot the early signs of dementia and on average. Extending the role of pharmacists into make referrals to the GP for a diagnosis.” areas such as prescribing and specialist referral could mean people with diabetes have more Jeremy Hughes, support when they most need it.” CEO Alzheimer’s Society

Simon O’Neill, Director of Health Intelligence, Diabetes UK “This report from the Royal Pharmaceutical Society highlights the important, indeed vital, role pharmacists are playing in supporting people with long term conditions. Its case “Seven in ten people with dementia live with one or studies and examples highlight the growing more other health conditions. With different doctors evidence that the greater use of pharmacists working in different parts of the health service within a multidisciplinary approach to care prescribing medicines to treat each condition, can improve outcomes, with the accessibility people with dementia often end up with complex, and convenience of the community pharmacy outdated treatment packages. Pharmacist-led setting providing an ideal place for expanding medicine reviews ensure holistic oversight of a the opportunities for prevention and screening person’s treatment, ensuring the medicines are as well as using the skills of community working effectively, complement each other and pharmacists to support those living with a long that a person is able to adhere to them. term condition. The report is a timely call to action, and the recently announced Pharmacy People living with one or more long term conditions Integration Fund should be used to develop need holistic and well co-ordinated support to these new pharmacy-based models of care, and live as well as possible for as long as possible. explore how we they should be commissioned Pharmacists can play a significant role in prevention, and delivered at scale. With increasing numbers early detection, supported self-care and ongoing of people living longer while managing one management of long term conditions. We all know or more long term conditions, it’s time for a that pharmacists need to be deployed much more change of pace in developing the pharmacist’s effectively to enhance the accessible, person- contribution through patient-centred approaches centred contribution they can make to health and that help people use medicines to achieve the wellbeing. It is now time to make this ambition a right result for them, while maximising the reality not just for small minorities of patients who efficient use of vital NHS resources.” benefit from pilots and innovation, but for everyone who lives with a long term condition.” Rob Darracott, Chief Executive, Dr Charlotte Augst, Pharmacy Voice Partnership Director, Richmond Group of Charities

6 Frontline pharmacists: Making a difference for people with long term conditions “High quality care for people living “The Faculty of Old Age Psychiatry welcomes with long term conditions depends on this report. It highlights the increasing substantial multidisciplinary working, number of people living with long term involving specialist and community nurses, physical or mental conditions with older pharmacists, allied health professionals, individuals in particular often having multiple social care workers, health care assistants, comorbidities. It stresses the importance of and others. health professionals including the pharmacist working collaboratively and in an integrated Nurses are often closely involved in the care manner across all systems to ensure the and assessment of people who are receiving person with the long term condition gets the long term care. Particularly in community best possible advice and support. and primary care settings, a specialist nurse will often assist other healthcare Older people with mental health issues professionals as much as patients: a benefit from early recognition of their specialist nurse will support GPs and symptoms and prompt signposting for practice nurses as well as providing advice support/treatment. Pharmacists are in a and support to patients. They often give unique position to see people with long advice and support which may prevent the term conditions on a regular basis and so need for secondary interventions. are well placed to recognise any signs and symptoms of mental health issues such as Nurses will also work closely with depression or dementia.” pharmacists regarding medicines management. In this way, their expertise is Dr Amanda Thompsell FRCPsych, central in supporting an integrated system Chair of the RCPsych’s Faculty of of care, from acute and specialist services Old Age Psychiatry to self-management.

Self-management is also important, and community nurses and community “Through its Future Hospital Programme, pharmacists can play a crucial role in the RCP has long recognised the importance helping individuals to manage their own of bringing care closer to the patient conditions. It is vital that people living by integrating care across the primary, with long term conditions are given the secondary and community care sectors. information and training to make choices As healthcare professionals on the high about where and how they want to street, pharmacists are there for patients live, and are supported by appropriate, and families every day. Enhancing their role competent staff.” as part of the multidisciplinary team will open up new opportunities to identify and Wendy Preston, manage patients with long term conditions, Head of Nursing Practice, help patients better manage their own Royal College of Nursing health and avoid hospital admissions.”

Dr Andrew Goddard, Royal College of Physicians

7 Frontline pharmacists: Making a difference for people with long term conditions THE PATIENT HEALTH The RPS believes that patients will benefit from further JOURNEY FOR LONG integration of pharmacists into their multidisciplinary team, ensuring support at every stage of their TERM CONDITIONS journey from prevention through to treatment and management of their long term condition(s).

People living with long term conditions must benefit The RPS believes that pharmacists will contribute, from access to the right health and social care skill with others, to the prevention and screening of set at the right time to meet their physical and disease, self-care and supporting patients diagnosed mental health needs. They should feel empowered with long term conditions from disease progression to act as decision-makers in their own care to help by supporting their health and wellbeing. shape their desired outcomes at all points of their long term condition journey. The RPS believes that commissioners should develop collaborative arrangements to enable pharmacists Figure 1 represents key stages in this journey. The with appropriate skills and knowledge to manage the role of pharmacists at each stage is further explored long term care of frail, elderly people living in care in this report. homes and other domiciliary settings.

Figure 1: The long term condition patient journey

2. iel detection

1. revention and self 4. anageent alliative and nd of Life lanning

3. reatent and onitoring

8 Frontline pharmacists: Making a difference for people with long term conditions PREVENTION AND Pharmacists play a particularly important role in the SELF-MANAGEMENT prevention of long term conditions. For example, obesity and smoking are risk factors for a number of long term conditions.36 Pharmacists are able to Everyone should be empowered and given the tools advise on reducing risks by providing information on to maintain their own health and wellbeing. The Self smoking cessation and weight loss through a number Care Forum describes a ‘four pillars of engagement’ of established community pharmacy programmes. approach to self-care: 1. Lifelong Learning; 2. Empowerment; 3. Information; and 4. Local and National Campaigns.32 Pharmacists are well placed 4. Local and national campaigns to support people at each point of this model: Pharmacists and community pharmacies are highly engaged with both local and national health 1. Lifelong learning campaigns. Community pharmacies are contracted to undertake at least six locally-determined public An estimated 1.6 million visits to community health campaigns every year,37 as well as their pharmacies take place daily, of which 1.2 million are involvement in national campaigns like ‘Stoptober’. for health-related reasons.33 This regular contact, Over 9,000 pharmacies in England supported without the need for an appointment, means Smoke Free January in 2015 and nearly 10,000 pharmacists are well placed to provide opportunistic pharmacies supported Stoptober in 2015.38 health education, advice and support and to make every contact count. This is particularly true for Giving people the information and tools to people with diagnosed long term conditions who make positive lifestyle choices and to engage in regularly interact with pharmacists when collecting self-care empowers patients and is an essential prescriptions. step in maintaining good health and preventing illness. Shifting resources to support people to stay in the prevention stage of the long term condition 2. Empowerment journey (see Figure 1) for as long as possible will help the NHS move from an illness service to a There are over 11,700 community pharmacies in wellness service. England.34 Most of the population in England (89%) is estimated to have access to a community pharmacy NHS England’s Five Year Forward View states that, ‘the within a 20 minute walk and access is even greater in future health of millions of children, the sustainability areas of highest deprivation (99.8%).35 This level of of the NHS, and the economic prosperity of Britain access is particularly important in the management all now depend on a radical upgrade in prevention of long term conditions, which are more prevalent in and public health’.39 lower socio-economic areas. The RPS believes that public health organisations should fund the use of community pharmacies 3. Information to target specific health promotion subjects that impact on the management of long term conditions. As a trusted healthcare profession, pharmacists provide a reliable and confidential source of health and medicines information. The pharmacy team can also ensure that patients are signposted to trusted 89% of the English population is resources and support groups, both national and estimated to have access to a community local, for further information about their physical pharmacy within a 20 minute walk. and mental health.

9 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY TYPE 2 DIABETES PREVENTION

Over the past 10 years, Lloyds Pharmacy has been to help find the millions of the number of people offering free screening people that are at risk or with diabetes in the UK nationwide for Type 2 have the condition and don’t has risen from 1.8 million diabetes since 2003 and has know it. Through engaging to 3 million. carried out over 1.5 million customers and patients in assessment checks. It is conversations about their estimated that had these health and lifestyle we can 3.0 been carried out by the help to identify them early NHS, it would have cost it and provide the necessary £18.5 million. The screening advice, guidance and

2.5 service has resulted in the signposting in a friendly and referral of over 75,000 familiar setting. people considered to be ‘at high risk’ to their GP The fact that we have 2.0 for further investigation or now performed over diagnosis. 1.5 million checks shows that pharmacy is an ideal place to 1.5 In 2013, the national provide such interventions. pharmacy chain launched Our services extend to a new foot check advice supporting people with a 1.0 service for diabetes patients. diagnosis, in helping them It was used by over 30,000 to manage their condition

People with diabetes in the UK (millions) People people in the first two weeks effectively, such as foot care 0.5 of it being available. awareness and medicines advice, which go some “Through our experience way to support the multi-

0 of providing the Lloyds speciality care required to 2006 2016 Pharmacy Type 2 Diabetes manage diabetes.” Screening Service in community pharmacies for Sam Preston, Prescription This growth is set to continue over 13 years, we know and Services Manager, over the next decade.40 there are many opportunities Lloyds Pharmacy

10 Frontline pharmacists: Making a difference for people with long term conditions TIMELY DETECTION This would improve access to care and reduce unnecessary appointments, enabling GPs to focus When someone first starts to experience the on diagnosing more complex conditions. It would symptoms of ill health, they may initially attempt also streamline the patient journey and improve to self-manage. At this stage, people will often seek cost efficiency. advice from a pharmacy; this is an ideal opportunity for pharmacists to detect the early warning signs of what Pharmacists already conduct a number of could potentially be diagnosed as a long term condition. screening programmes for long term conditions. More opportunities for simple testing for long Early detection and timely referral can make a term conditions should be explored as part of a significant difference to patients’ quality of life, preventative approach to healthcare, for example particularly in conditions such as dementia.41 The atrial fibrillation detection, blood pressure regularity with which pharmacists see patients monitoring for hypertension and testing blood sugar means that they are well placed to detect signs levels for diabetes. and symptoms of some long term conditions on an opportunistic basis.

Currently, the primary health care system includes barriers to direct referral from one health professional to another. When someone presents at a pharmacy with symptoms which require referral, the pharmacist has few options other than the traditional route of recommending that they visit their GP. The pharmacist may have already recognised that the patient would benefit from direct access to another healthcare professional, such as a dietician or physiotherapist, but this currently requires onward referral from a GP. This adds additional burden to the already overstretched GP network and can lead to delays in access to treatment.

The RPS believes that pharmacists should be an integral part of referral systems within the multidisciplinary team. Pharmacists should be able to directly refer to other health and social care professionals for minor health conditions. Pharmacists should also be referred to for common ailments, medicines reviews and the ongoing monitoring, support and treatment of patients with long term conditions.

11 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY EARLY DETECTION OF ATRIAL FIBRILLATION THROUGH ‘ENHANCED’ MEDICINES REVIEWS

Atrial fibrillation (AF) use reviews to patients and are checking that they are increases the risk of stroke, are ideally situated to facilitate receiving optimised treatment reduces quality of life, and the diagnosis of AF. and are taking anticoagulants. increases morbidity and As part of the consultation, mortality.42 A significant The Royal Brompton and the pharmacists are using a number of patients who Harefield NHS Foundation portable electrocardiography have AF are asymptomatic, Trust is currently running a (ECG) device, called an which often leads to a delay programme to assess how AliveCor monitor, to detect in diagnosis. Too often, the detection and treatment AF. AF is only detected when of AF can be improved the patient presents with via ‘enhanced’ medicines Patients who are found to serious complications, such use reviews in community have undiagnosed AF, are not as a stroke. Anticoagulation pharmacies.44 appropriately anticoagulated, reduces the risk of stroke, but have poor heart rate control, data have shown that only Ten community pharmacists or have high symptom around half of patients eligible are carrying out detailed burden, will be referred for an anticoagulant actually medicines reviews for patients to the Arrhythmia Care receive one.43 with risk factors for developing Team at Harefield Hospital, AF, for example high blood where they will be reviewed Community pharmacists pressure or diabetes. In and offered individualised currently provide medicines patients with existing AF, they treatment.

12 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY ATRIAL FIBRILLATION SCREENING

Many patients with AF are The service also identified Pharmacists provided 413 asymptomatic and diagnosed 109 patients with interventions in 326 patients via opportunistic screening. undiagnosed hypertension, aimed at weight reduction Community pharmacy has 176 patients with a BMI of (239), alcohol consumption been advocated as a potential >30,131 with an Audit-C (123) and smoking cessation resource for opportunistic score of more than 5, and (51). screening and lifestyle 59 smokers. interventions. This service evaluation revealed that patients are During October 2014 – willing to be screened for January 2015, six pharmacies AF through community in Kent undertook AF pharmacies and that screening among eligible pharmacists are able to patients as identified through identify patients at risk of AF pharmacy records and as well as other risk factors the completion of a short to health. Community questionnaire.45 Of 594 pharmacists were able to patients screened, nine were  Weight reduction provide advice to patients identified as at risk of having and make GP referrals as a AF and were referred to  Alcohol consumption result of this opportunistic their GP.  Smoking cessation screening.

Pharmacists provided 413 interventions in 326 patients aimed at weight reduction (239), alcohol consumption (123) and smoking cessation (51)

13 Frontline pharmacists: Making a difference for people with long term conditions TREATMENT AND The RPS believes that commissioners, NHS Trusts, MONITORING GP surgeries and community pharmacies should develop collaborative arrangements for specific categories of patients with long term conditions to Once a patient has been diagnosed with a long be partly or completely managed by pharmacists. term condition and stabilised by their GP or specialist, ongoing support should be provided by The RPS believes that steps should be taken an appropriate multidisciplinary team to provide at national and local levels to develop ways of patient-centred, integrated care. working that enable health professionals to operate efficiently and effectively across traditional When prescribed and taken appropriately, medicines sectors. have the potential to significantly improve quality of life and health outcomes for people living with long The RPS believes that opportunities must be created term conditions. for multidisciplinary teams to train and develop together to encourage greater collaboration and 30 50% sharing of expertise. The RPS believes that pharmacists must have protected time to advance their practice and to However, it is estimated that between sustain their professional development. 30-50% of medicines prescribed for long term conditions are not taken correctly.46 Multimorbidity and polypharmacy

It has been suggested that improving the effectiveness Alongside the rise in numbers of people living with of adherence interventions may have a far greater several long term conditions (multimorbidity), it also impact on the health of the population than any recognised that these patients experience poorer improvement in specific medical treatments.47 A quality of life, poorer clinical outcomes, longer report in 2010 stated that up to £500 million of extra hospital stays, more post-operative complications value could be ge ne r ated in jus t fi ve the r apeu tic ar ea s and are therefore more costly to health services.50 (asthma, diabetes, raised blood pressure, vascular disease and the care of people with schizophrenia) if medicines were used in an optimal manner.48 People living with long term conditions are also more likely to need complex The principles of medicines optimisation describe medicines regimens with more intensive how healthcare professionals can enable patients support from health professionals. to improve their quality of life and outcomes from medicines use by having a sustained focus on the need to optimise patients’ medicines.49 By focusing The rise in the number of people living with multiple on a holistic approach to pharmaceutical care and long term conditions is recognised as a key factor in optimisation of medicines, pharmacists can support the increase in prescribing rates. The proportion of people living with long term conditions to maintain patients receiving ten or more medicines has grown good health and avoid complications, as well as from 1.9% in 1995 to 5.8% in 2010 and the average working to prevent the development of further number of items per person increased by 53.8% conditions. between 2001 and 2011.51

14 Frontline pharmacists: Making a difference for people with long term conditions The use of multiple medicines (polypharmacy) can There are currently 3,319 independent pharmacist become problematic when medicines are prescribed prescribers in Great Britain.56 Pharmacist prescribers inappropriately, or where the intended benefit of can increase capacity in primary care by taking the medication is outweighed by the risk. The more on some of the prescribing burden for long term medicines an individual is prescribed, the greater the conditions. risk of drug interactions and adverse drug reactions, as well as impaired adherence to medicines and a The RPS believes that pharmacists must play an reduced quality of life.52 important role in the safe management of people with one or more long term conditions, who are taking several medicines (polypharmacy), by Research also demonstrates that people with improving adherence to treatment, reducing side long term conditions are two to three times effects and admission to hospital, and de-prescribing more likely to experience mental health where appropriate. problems than the general population. The RPS believes that pharmacists providing direct patient care should have the opportunity to train Much of the evidence relates specifically to affective to become a prescriber, fully utilising those skills as disorders such as depression and anxiety, however part of the multidisciplinary approach to managing multiple morbidities are also common in dementia, and supporting people with long term conditions. cognitive decline and some other conditions.53

As the number of people living with multiple long term conditions become more prevalent, the challenges associated with prescribing the right medicines and supporting patients to use them effectively should not be underestimated. This increase in complexity means that, besides developing and maintaining prescribing competency for individual conditions, prescribers are faced with the challenge of keeping up-to-date with new medicines, managing the risk of adverse events and the potential for interaction between medicines prescribed for different conditions.54,55

Managing polypharmacy is where the expertise of the pharmacist is an essential part of multidisciplinary approaches to care. Pharmacists’ in-depth pharmacology, therapeutics and medicines expertise is extremely valuable when considering the optimal medicines regimen for a person with multiple morbidities. Ensuring the appropriate use of medicines, stopping inappropriate medicines, as well as considering opportunities for lifestyle changes and non-medical therapies are key areas in which pharmacists can play a leading role.

15 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY PHARMACIST MANAGEMENT OF ASTHMA REVIEWS

“Research has shown that Of those reviewed: The study found considerable the delivery of regular improvement in patients’ structured reviews of people 42% of patients compliance with their with asthma can reduce had not had an medicines, resulting in better their day-to-day symptoms asthma review overall asthma control. and reduce the burden of at their GP providing emergency care practice in the The study demonstrated on the NHS. However, it last 12 months ➽ is reported that only two- thirds of patients with 32% asthma have a routine decrease in GP appointments

asthma review each ➽ year. 57 Asthma reviews 56% had are mainly undertaken by not had 40% practice nurses and GPs. their inhaler reduction in hospital admissions The Signposting, Inhaler technique technique, Medication, Peak checked in flow, Lifestyle and Education the last year. The project team concluded (SIMPLE) intervention that to improve patient package was developed to outcomes and thus decrease assess the potential value hospital admissions, pharmacist of patients receiving a asthma reviews should be structured review at their Using the validated Asthma targeted at patients who community pharmacy.58 Control Test (ACT) the have not had a review from results showed most the GP recently, capitalising In collaboration with improvement in those on the accessibility and other health professionals, patients who had not had approachability of the community pharmacists an asthma review from their community pharmacist.” were given extra training to GP in the last 12 months; deliver structured asthma showing patients receiving Anna Murphy, reviews. 13 pharmacists significant clinical and quality Consultant Respiratory carried out reviews in of life improvement. Pharmacist at University Leicester city centre on Hospitals of Leicester NHS Trust 165 patients with follow-up It is known that people and honorary visiting professor, appointments at three and only take their medicines as School of Pharmacy, six months. prescribed 50% of the time DeMontfort University which leads to poor outcomes and wasted resources.59

16 Frontline pharmacists: Making a difference for people with long term conditions The New Medicines Service treatment. The intervention patient outcomes at overall is based on the pharmacist reduced costs to the NHS.60 The New Medicine Service having a consultation with the (NMS) is offered in England patient 7-14 days after initial The NMS significantly increased by community pharmacists presentation with a prescription adherence by about 10% to people starting a new for a new medicine. and increased numbers of medicine to help improve medicines problems identified medicines adherence for the A 2014 evaluation of the NMS and dealt with, compared with following long term conditions: showed that it significantly current practice.61 The NMS asthma/chronic obstructive increased patients’ adherence alone has been estimated to pulmonary disease (COPD), to their new medicine and that have generated £17.3 million in type 2 diabetes, hypertension delivery of the service will save health system cost savings net or antiplatelet/anticoagulant the NHS money through better of the cost of delivery.62

CASE STUDY THE FOUR OR MORE MEDICINES SERVICE

Inappropriate prescribing and prescribing of nonsteroidal anti- through 11,100 pharmacies in non-adherence have a significant inflammatory drugs (NSAIDs), England to 954,600 patients, the impact on hospital admissions proton pump inhibitors (PPIs) or NHS would see annual benefits of: and patient quality of life. The duplication of therapy. • £35.57 million in reduced English government has identified medicines costs and hospital that community pharmacy could After six months, patients had admissions as a result of STOPP make a significant contribution experienced a significant: / START recommendations to reducing non-adherence • increase in medicines adherence; • £33.87 million in reduced and improving the quality of • reduction in medical and hospital costs due to reduction prescribing, reducing both self-treated falls; and in falls that result in fractures. hospital admissions and medicines • increase in patient quality of life. • a total of 17,200 Quality wastage. Four or more medicines Adjusted Life Years (QALYs). (FOMM) is a community Pharmacy teams picked up on a pharmacy support service aimed range of issues - not all medicines Benefits as a result of improved at patients >65 years old who are related. Patients were more medicines adherence, pain, taking four or more medicines.63 satisfied with the management and falls that do not require of their condition - a key NHS secondary care treatment have In an evaluation of this service, objective. Quality of life was not been quantified. 620 patients were recruited by improved in small but significant 25 pharmacies across all socio- ways, such as advising on the This study shows that by demographic areas across Aston, correct length of walking sticks focusing on patients over the Leigh and Wigan. 441 (71.1%) and how medicines could fit in age of 65 years with four or completed the six-month study with home and social life. more medicines, community period. Pharmacists made 142 pharmacists can improve medicine recommendations to prescribers Based on the findings from the adherence, clinical outcomes and in 110 patients largely centered FOMM Service, it is estimated patient quality of life – all at a on potentially inappropriate that if the service was delivered potential cost-saving to the NHS.

17 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY PHARMACIST PRESCRIBERS: ANTI-COAGULATION SERVICE

“Regulations to allow Once patients are referred • Freed up capacity in pharmacists to prescribe by their GP, independent the Trust haematology independently for any pharmacist prescribers department allowing condition within their clinical (IPs) carry out a thorough increased focus on patients competence came into effect consultation with patients and and inpatients with more in 2006.64 Pharmacists at where clinically indicated, the complex needs Boots UK have been caring IPs can prescribe the patient’s for patients taking warfarin anticoagulant of choice. • Fantastic clinical by initiating therapy and Patients who are prescribed development route for monitoring ongoing dosing warfarin then go on to join the pharmacists to train through community-based Boots Anticoagulation Service and practice as IPs; anticoagulation services for for ongoing management and demonstrating how almost 10 years. patients who choose a Direct pharmacy supports the wider Oral Anticoagulant (DOAC) health system Following the publication of are monitored for a period of the updated Atrial Fibrillation three months before their care I was the first IP to pioneer National Institute for Health is transferred back to their GP. this new model of care in the and Care Excellence (NICE) Bromley service and wrote guidelines in June 201465 which Since the introduction of the first FP10 prescription. It included the recommendation the new pathway in January was a very proud moment for that the decision around 2016, Boots IPs have initiated Pharmacy, for Boots UK and for anti-coagulation treatment either warfarin or a DOAC me to carry out an activity that should be made after an for over 80 patients resulting would have historically only informed discussion between in significantly positive been done in secondary care. clinician (including pharmacist outcomes. We have moved from being clinicians), and the patient, a fragmented pathway across Boots worked closely with Key findings: primary and secondary care to Bromley CCG to develop offering a more complete and a new clinical pathway to • Extremely positive patient seamless level of care for our support the guidelines. satisfaction with regular patients. Developing similar The new pathway uses 100% scores in patient pathways in other regions independent pharmacist feedback questionnaires would I believe, benefit the prescribers to encourage health system as a whole.” a shared decision making • Patients seen in clinics discussion with patients to within days of the completed Shirley Walker, Healthcare offer all available treatments referral being received, Partnership Manager and for anticoagulation, not just minimising potential delays Independent Prescriber, warfarin. to initiating therapy Boots UK

18 Frontline pharmacists: Making a difference for people with long term conditions Caring for people living about the appropriateness prescribed bone protection with multiple long term of the medications she was supplements which she was conditions currently being prescribed clearly in need of. She also and had requested a review had a very poor inhaler In 2012, the Central London be carried out at the technique. Community Healthcare patient’s home. NHS Trust began running a I liaised with the MDT pilot to support medicines On visiting the patient, I to make the necessary optimisation in the >65s. saw numerous medications adjustments to the patient’s The service involved the scattered around her medications. I was able to Clinical Medication Review home. Blister packs from counsel her on her inhaler Pharmacist, alone or previous prescriptions were technique and also referred accompanied by a GP or evident as were expired her to the local memory nurse, visiting the elderly medications. The patient service and I provided her patients in their home to was evidently drowsy, with a medication chart as a conduct a Level 3 medicines even though it was the reminder of what she should review. Patients were middle of the day, and be taking and what each referred by any member she had stomach pain. medicine was for. She was of the multidisciplinary She was unclear what the subsequently diagnosed with team (MDT). The patients medications she was taking mild-moderate dementia. were mostly housebound were for and was taking and taking a number of them incorrectly. On my second visit to the medications for long term patient, accompanied by the conditions. On the basis of On assessment of her district nurse, it was evident its success, the service was medications, I found that her that the patient was much re-commissioned following antihypertensive medication improved. She no longer the pilot. (for very low blood pressure had stomach pain, her blood and risk of falls) had been pressure had improved and A member of the Medicines stopped in hospital but this she was much more alert. Management Team - change had not been carried It is likely that her risk of Clinical Medication Review through on discharge. I falls and stroke had been Pharmacist, Nicole Le found her to be on too low reduced, and she was finding Morgan - describes one of a dose of anticoagulant given the medication chart to be her recent cases: her high risk of stroke. Her helpful with compliance. drowsiness was due to her “A GP referred an elderly taking a sleeping tablet late Through a 45-minute visit lady to me who had been at night to relieve itching to the patient in her home, I discharged from hospital which, in turn, was due to was able to get a full picture with queried dementia. the pain-relief patches she of the medication needs The lady had COPD, had been prescribed years of the patient. As well as hypertension, chronic pain ago for lower back pain, adjusting her medications, I as a result of osteoarthritis, but were actually no longer was also able to put her in and atrial fibrillation. She required. She had been touch with other services was also at a high risk of missed off the flu jab list critical to her holistic falls. The GP was unclear and was not currently being wellbeing.”

19 Frontline pharmacists: Making a difference for people with long term conditions PALLIATIVE AND END The RPS believes that all pharmacists directly OF LIFE CARE involved in patient care should have full read and write access to the patient health record, with patient consent, in the interest of high quality, safe Palliative and end of life care are not necessarily and effective patient care. an inevitable part of the long term condition cycle. People can live well with a long term condition, Medicines can be of significant benefit during end providing that it is managed effectively. However, of life care to control pain, alleviate symptoms should a patient’s condition begin to deteriorate, and stabilise conditions. This is an area in which it could become a necessary extension of their patients can benefit significantly from the support treatment and management plan, as illustrated in and expertise of a pharmacist to help them make Figure 1. decisions about their medicines and healthcare.

People with palliative care and end of life care There are often problems in accessing palliative needs must be treated with dignity and respect and care medicines in the last few days of life as the empowered to shape their own patient journey.66 needs of the patient change rapidly, especially for End of life care can be a very difficult process for opioids or for injectables for syringe drivers. Access families and carers; some may have to take over to medicines needs to be effectively managed to decision-making for their relative and so it is vital avoid medicines wastage. Within an area, a network that families and carers are supported and given as of pharmacists could be established that hold such much advice and information as they need, at a time supplies and have expertise within this area of care. that is appropriate for them. Support for the patient and carer or family must also include dialogue between the whole multidisciplinary health team, social care and third sector to ensure the patient’s needs are effectively met in the care setting of their choice. Co-ordination and communication across the multidisciplinary team will be critical to delivering high quality and responsive palliative and end of life care. This can be facilitated by read and write access to the electronic patient record.

20 Frontline pharmacists: Making a difference for people with long term conditions CASE STUDY MANAGING END OF LIFE THROUGH AN EFFECTIVE MULTIDISCIPLINARY TEAM67

The NICE Quality Working with the local Through these initiatives, there Standard 1368 specifies palliative care team, the MDT was a reduction of more than that palliative care implemented several initiatives 40% in admission to hospital must be developed to improve upon this: for end of life care from in accordance with a 2013-2016. 36% of patients personalised care plan, • Training and support had anticipatory medicines in including rapid access for nurses in homes and place at time of death which to administration of community pharmacists; were used in 61% of patients. medicines, and should The initiatives resulted in the also consider the patient’s • Joint MDT working and increased empowerment of needs and preferences for scheduled visits to provide nurses, carers and pharmacists, place of death. truly holistic patient-centred and improved facilitation of care; patient and family wishes at In 2013, the Argyle end of life. Care Home Service was • Development of formulary commissioned by Ealing of anticipatory medicines Nursing home manager’s CCG to provide medical designed to meet the needs feedback: and pharmaceutical of most patients; care to patients across “With the support [the 19 nursing homes. The • Identifying pharmacies MDT] give, our residents multidisciplinary team that will stock and supply generally die within the (MDT) consisted of anticipatory medicines home around faces they GPs, an independent urgently; recognise. I hope the Argyle prescribing practice Surgery will continue to run nurse, and full skill mix • Improving communication the Home Service in future of clinical and prescribing between the ‘trinity’ of as this makes the difference pharmacists and pharmacy home, general practice and between residents dying with technicians. Prior to this, pharmacy; dignity around people they nursing home patients’ care for or residents being deaths in hospital were • Support and teaching for rushed off to hospital in an significantly higher than doctors, GP pharmacists and emergency and dying without the national average and pharmacy technicians; and dignity around people they deaths in nursing homes don’t. As all our residents significantly lower. • Integrated working with have dementia, this makes community pharmacies to a real difference to patients ensure timely supply. and families.”

21 Frontline pharmacists: Making a difference for people with long term conditions NEXT STEPS

This report has been developed to instigate action at national and local levels to ensure people with long term conditions can benefit from greater access to the expertise of pharmacists.

Implementation of this report’s recommendations will help to drive quality improvements in the delivery of care by the multidisciplinary team and will contribute to the changes needed to reduce demands on health and social care services, including emergency care in England.

Action will be required across NHS England to review current plans for long term conditions and to address the role that the pharmacy profession can play in the development of effective models of care. This should be a key element of the new Sustainability and Transformation Plans.

The RPS in England is committed to working with the NHS and other partners to drive this important agenda forward and to evaluate its effectiveness in improving patient care.

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24 Frontline pharmacists: Making a difference for people with long term conditions Published by: Royal Pharmaceutical Society 66-68 East Smithfield London E1W 1AW 0845 257 2570